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  • Writer's pictureStephen Harden

A Just Response

by: Steve Montague

Over the past few months, I’ve faced a new challenge as I work to apply aviation techniques and tools in health care. It usually goes something like this: “Why should we pursue aviation-based culture when the airline industry has crews that fly 150 miles past Minneapolis?”

My response usually begins by noting that even though some of the information has been made public, very few informed voices have actually been heard in the mainstream media. James Reason, professor emeritus at Manchester University and author of the book “Human Error”, perfectly predicted the response from the FAA, the airline, the media, and the general public. That response was basically, “Hang the guilty bastards.” Dr. Reason warns us that blaming individuals is our reflexive response because it is easy and emotionally satisfying. If we simply get rid of the careless and incompetent practitioners then this will never happen again. Sound familiar?

Suffice it to say that an intelligent response to human error requires a systems approach to analyzing what happened, what interventions will prevent reoccurrence of the error, and only then, taking appropriate actions such as training, policy changes, and perhaps punishment.


The only way we know what happened in this incident, as well as the numerous non-incidents that occur every day as discussed above, is that the cockpit crew fully disclosed exactly what happened and did not obstruct the investigation in any way. In fact, this culture of open communication is what provided the resilience necessary to prevent a more serious outcome than the flight landing safely and less than an hour late.

How does your organization encourage such transparency? Implementing a thoughtful incident reporting and response algorithm that includes the following questions, is a great place to start.

Was the behavior other than what one would reasonably expect in this situation?

If so, was it due to ignorance or a simple lapse of memory?

If not the above, was it due to negligence, recklessness, or willful violation of regulation, procedure, or protocol?


This system is not intended to eliminate individual accountability. It is a transparent system designed to mitigate the impact of, and more importantly learn from and reduce, individual error. While this open disclosure begins with debriefing, a reporting culture raises awareness of latent error in systems and processes and helps avoid embarrassing outcomes. . . or worse.

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